PFD report

Andrew BIDDLECOMBE · Prevention of Future Deaths report

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Issued 25 Feb 2021•Hampshire, Portsmouth and Southampton

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to inform the DVLA of medical conditions relevant to safe driving
    Part of recurring concern: Inadequate driver licensing controls for road safetyPart of recurring concern: Unreliable DVLA medical fitness notification arrangements
  2. Failure to advise drivers of the legal requirement to notify the DVLA of medical conditions
    Part of recurring concern: Unreliable DVLA medical fitness notification arrangements
  3. Failure to advise drivers of the impact of their medical conditions on safe driving
    Part of recurring concern: Unreliable DVLA medical fitness notification arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Write to patients with epilepsy or Parkinson’s disease to remind them of DVLA notification responsibilities and identify current drivers for record updates.

    Stated by Emsworth SurgeryStated completedThe respondent said that this action was complete when they made their response on 1 March 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to inform the DVLA of medical conditions relevant to safe driving

Wider context from the report

“The deceased was 70 years of age. The deceased had several medical conditions including Parkinson’s disease; had suffered possible epileptic seizures; had bilateral posterior capsular opacity. The deceased was known to have problematic double vision and was partially sighted in his right eye. The deceased was known to have poor mobility. The deceased was prescribed medications namely Ipninia XL a medication with a recognised side-effect of sudden sleep onset episodes and Ramipril a medication with recognised side-effects of blurred vision, confusion and dizziness. It was known that the deceased was a current driver, noting the Parkinson’s review in February 2020. The deceased had not been advised of the impact of his medical conditions on his ability to drive safely nor had he been advised of the legal requirement to notify the DVLA of his medical conditions. The practice did not inform the DVLA of the deceased’s medical conditions relevant to the deceased’s ability to drive safely. ”

Is this part of a recurring concern?

Yes — Inadequate driver licensing controls for road safety; Unreliable DVLA medical fitness notification arrangements.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to advise drivers of the legal requirement to notify the DVLA of medical conditions

Wider context from the report

“The deceased was 70 years of age. The deceased had several medical conditions including Parkinson’s disease; had suffered possible epileptic seizures; had bilateral posterior capsular opacity. The deceased was known to have problematic double vision and was partially sighted in his right eye. The deceased was known to have poor mobility. The deceased was prescribed medications namely Ipninia XL a medication with a recognised side-effect of sudden sleep onset episodes and Ramipril a medication with recognised side-effects of blurred vision, confusion and dizziness. It was known that the deceased was a current driver, noting the Parkinson’s review in February 2020. The deceased had not been advised of the impact of his medical conditions on his ability to drive safely nor had he been advised of the legal requirement to notify the DVLA of his medical conditions. The practice did not inform the DVLA of the deceased’s medical conditions relevant to the deceased’s ability to drive safely. ”

Is this part of a recurring concern?

Yes — Unreliable DVLA medical fitness notification arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to advise drivers of the impact of their medical conditions on safe driving

Wider context from the report

“The deceased was 70 years of age. The deceased had several medical conditions including Parkinson’s disease; had suffered possible epileptic seizures; had bilateral posterior capsular opacity. The deceased was known to have problematic double vision and was partially sighted in his right eye. The deceased was known to have poor mobility. The deceased was prescribed medications namely Ipninia XL a medication with a recognised side-effect of sudden sleep onset episodes and Ramipril a medication with recognised side-effects of blurred vision, confusion and dizziness. It was known that the deceased was a current driver, noting the Parkinson’s review in February 2020. The deceased had not been advised of the impact of his medical conditions on his ability to drive safely nor had he been advised of the legal requirement to notify the DVLA of his medical conditions. The practice did not inform the DVLA of the deceased’s medical conditions relevant to the deceased’s ability to drive safely. ”

Is this part of a recurring concern?

Yes — Unreliable DVLA medical fitness notification arrangements.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Write to patients with epilepsy or Parkinson’s disease to remind them of DVLA notification responsibilities and identify current drivers for record updates.

Verbatim wording from the response

“Emsworth Surgery have undertaken a significant event analysis as part of the action arising from the Regulation 28 Report received. We have reviewed the templates that could be used for chronic disease review to ensure there are questions relevant to the patient’s driving status. We have also written to all our patients on the Epilepsy and Parkinson’s Disease register to remind them of their responsibilities to inform the DVLA of their diagnosis. We have asked the patients on these registers to inform us if they are current drivers so we can ensure their records are up to date. Finally, we have sent a medication leaflet to all patients on Ropinirole detailing possible side effects including sudden drowsiness to remind patients of these and the importance of reporting side effects.”

Source location

2021-0053-Response-from-Emsworth-Surgery_Published
Page 2 · response
Published 1 March 2021

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Send Ropinirole patients medication leaflets explaining possible side effects, including sudden drowsiness, and the importance of reporting them.

    Stated by Emsworth SurgeryStated completedThe respondent said that this action was complete when they made their response on 1 March 2021.
  2. 2

    Review chronic disease review templates to ensure they include questions about patients’ driving status.

    Stated by Emsworth SurgeryStated completedThe respondent said that this action was complete when they made their response on 1 March 2021.
  3. 3

    Undertake a significant event analysis in response to the Regulation 28 Report.

    Stated by Emsworth SurgeryStated completedThe respondent said that this action was complete when they made their response on 1 March 2021.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Send Ropinirole patients medication leaflets explaining possible side effects, including sudden drowsiness, and the importance of reporting them.

Verbatim wording from the response

“Emsworth Surgery have undertaken a significant event analysis as part of the action arising from the Regulation 28 Report received. We have reviewed the templates that could be used for chronic disease review to ensure there are questions relevant to the patient’s driving status. We have also written to all our patients on the Epilepsy and Parkinson’s Disease register to remind them of their responsibilities to inform the DVLA of their diagnosis. We have asked the patients on these registers to inform us if they are current drivers so we can ensure their records are up to date. Finally, we have sent a medication leaflet to all patients on Ropinirole detailing possible side effects including sudden drowsiness to remind patients of these and the importance of reporting side effects.”

Source location

2021-0053-Response-from-Emsworth-Surgery_Published
Page 2 · response
Published 1 March 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review chronic disease review templates to ensure they include questions about patients’ driving status.

Verbatim wording from the response

“Emsworth Surgery have undertaken a significant event analysis as part of the action arising from the Regulation 28 Report received. We have reviewed the templates that could be used for chronic disease review to ensure there are questions relevant to the patient’s driving status. We have also written to all our patients on the Epilepsy and Parkinson’s Disease register to remind them of their responsibilities to inform the DVLA of their diagnosis. We have asked the patients on these registers to inform us if they are current drivers so we can ensure their records are up to date. Finally, we have sent a medication leaflet to all patients on Ropinirole detailing possible side effects including sudden drowsiness to remind patients of these and the importance of reporting side effects.”

Source location

2021-0053-Response-from-Emsworth-Surgery_Published
Page 2 · response
Published 1 March 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake a significant event analysis in response to the Regulation 28 Report.

Verbatim wording from the response

“Emsworth Surgery have undertaken a significant event analysis as part of the action arising from the Regulation 28 Report received. We have reviewed the templates that could be used for chronic disease review to ensure there are questions relevant to the patient’s driving status. We have also written to all our patients on the Epilepsy and Parkinson’s Disease register to remind them of their responsibilities to inform the DVLA of their diagnosis. We have asked the patients on these registers to inform us if they are current drivers so we can ensure their records are up to date. Finally, we have sent a medication leaflet to all patients on Ropinirole detailing possible side effects including sudden drowsiness to remind patients of these and the importance of reporting side effects.”

Source location

2021-0053-Response-from-Emsworth-Surgery_Published
Page 2 · response
Published 1 March 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026